Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | 32106 | NE |
NPI | 1013413335 |
---|---|
Provider Name | Colin Alexander Henderson |
First Address | Joint Base Lewis Mcchord, WA 98431-0001 |
Second Address | Joint Base Lewis Mcchord, WA 98431 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/04/2018 |
Last Update Date | 05/11/2019 |